Adhesions can be caused by the following:

• Denovo Adhesions Occur as a result of
• Blunt Trauma
• Bladder Trauma
• Gall Bladder & Gynecological Surgery
• Endometriosis Pain with Diagram
• Increases in Operative Adhesive, etc
• Pain after Surgery
• Pain Following Radiation

Denovo Adhesions Occur as a result of, etc...

• De novo adhesions occur as a result of the surgical procedure 
• Reformed adhesions occur at the same location as previous adhesions that were lysed or resected

Abstract
Most patients with intestinal obstruction have had previous surgery. Rarely, the development of adhesions and 
resulting small bowel obstruction is attributed to previous intra-abdominal trauma. We present the case of a young man, without a history of surgery, who had been a restrained driver in a motor vehicle crash. Seven years later, the patient had an intermittent partial small bowel obstruction that recurred over the next 5 years. We review the pathophysiology and epidemiology of similar occurrences, as well as diagnostic options. [South Med J 94(5):499-501, 2001. © 2001 Southern Medical Association] 

Introduction
Intra-abdominal adhesions cause most mechanical small bowel obstructions.[1,2] Most adhesions are due to previous intra-abdominal surgery.[2,3] In patients without a surgical history, intra-abdominal adhesions have rarely been attributed to blunt abdominal trauma.[1,2,4,5]
We report a case of a young man who was the restrained driver in a car crash. He had no history of laparotomy or intra-abdominal disease. After a protracted course of recurrent pain, adhesional intermittent partial small bowel obstructions were diagnosed. Abdominal trauma may be an under-recognized cause of obstructing intestinal adhesions.
Case Report
This 33-year-old man had had intermittent abdominal pain for 5 years. Approximately once a year, he had an episode of lower abdominal "tightening" and "spasm." The symptoms lasted 10 to 24 hours and were associated with nausea and vomiting. He limited his diet to clear liquids, toast, and crackers until the pain remitted. Between these episodes, he had no gastrointestinal symptoms. 
Twelve years before this presentation, he had been the restrained driver in a motor vehicle crash, which had caused abdominal wall contusions, transient microscopic hematuria, a clavicular fracture, and a pneumothorax. He had not required surgery, and computed tomography had not been done. He had no other medical history; he denied surgery, abdominal radiation, intra-abdominal infection, and inflammatory diseases of the bowel. 
Previous studies included small bowel radiography, barium enema, magnetic resonance imaging (MRI) of the abdomen, colonoscopy, urine porphyrin testing, and stool studies for ova and parasites. These were all unremarkable. The patient was intermittently treated with famotidine, dicyclomine, hyoscyamine, and omeprazole. There was no change in frequency, duration, or severity of symptoms. Family history and social history were unremarkable. 
The patient was a well-appearing tall, thin man. He was afebrile and normotensive, and findings on physical examination, including the abdominal and rectal examinations, were normal. 
To further investigate the source of pain, an enteroclysis and a Meckel's scan were done (while the patient was asymptomatic). Results of both were normal. 
Four months after these tests, the abdominal pain recurred. While he was still symptomatic, another enteroclysis was done, which showed kinking of the small bowel at an acute angle. The contrast material moved slowly and pooled. This was diagnostic of an adhesional small bowel obstruction
At laparoscopy
Extensive small bowel adhesions were found, and several discrete bands were causing kinking in the distal 
jejunum (Fig 2). Lysis of adhesions was done during the laparoscopy. The bowel was normal in appearance,
without stenosis, stricture, or inflammation. After 1 year of follow-up, the patient is well and has had no further 
episodes of abdominal pain.

Discussion
Adhesions from previous surgery cause most small bowel obstructions.[2,3] Combining the data from three published studies yielded a total of 1,730 patients with adhesional small bowel obstructions.[2,6,7] The vast majority of patients had a history of previous surgery, and only 218 patients (12.6%) had no surgical history. In 129 (60%) of the nonsurgical patients, an etiology was identified -- most often tuberculous peritonitis, a history of intra-abdominal inflammation, or a history of pelvic inflammatory disease. In one patient, the adhesions were attributed to abdominal trauma, occurring 3 weeks before the development of obstruction.[2] In 89 (40%) of the nonsurgical patients, there was no identifiable cause for the adhesions.[2,6,7] 
In our case, a restrained driver in a motor vehicle crash had significant abdominal trauma, causing abdominal wall ecchymoses and microscopic hematuria at the time of the crash. Seven years later, intra-abdominal adhesions caused intermittent small bowel obstructions with associated abdominal pain. Although the motor vehicle crash and adhesional small bowel obstruction may be coincidental in our patient, there is no other explanation for the development of adhesions. Our case, therefore, suggests that the intra-abdominal trauma may have caused the development of adhesions and subsequent small bowel obstruction. A subset of patients with "idiopathic" adhesions may have had a history of remote abdominal trauma. 
In 1962, Garrett and Braunstein[8] first described the "seat belt syndrome," which encompassed a spectrum of 
intra-abdominal injuries caused by the seat belt during impact. In one study, 5% to 15% of patients sustaining blunt abdominal trauma had intestinal injury occurred.[9] The intestine is, in fact, the third most commonly injured intra-abdominal organ in the seat belt syndrome.[9] Relatively fixed portions of bowel, such as the proximal jejunum and distal ileum, are more susceptible to injury.[5,10,11] The mobile portions are able to escape the highest pressure and the resultant damage.[11] 
Motor vehicle crashes cause intestinal injury by several mechanisms. As an individual is propelled forward upon impact, the seat belt or buckle inflicts pressure -- throwing the intestine against the vertebral column and causing a contusion.[4,12-14] Also, rapid deceleration may shear fixed ligaments and mesenteric attachments.[12-16] 
Surgery and trauma result in peritoneal injury, the impetus for the development of adhesions. After surgery, the peritoneal surface is denuded and the microvasculature is disrupted, releasing a serosanguineous exudate that is followed by the formation of a fibrinous bridge.[3,17,18] Since fibrinolysis requires an adequate blood supply, tissue injury in an avascular milieu is associated with diminished fibrinolysis and a persistent fibrinous bridge.[3,17] Collagen is deposited 4 to 5 days later, and permanent adhesions result.[18] Since abdominal trauma is another cause of peritoneal injury, it is a logical supposition that adhesions could form in this scenario. 
The seat belt syndrome includes acute intestinal injury, as well as the less common delayed small bowel obstruction.[5,12-16,19,20] Most patients have symptoms 2 to 3 weeks after a crash and go to their physician 4 to 18 weeks after the trauma, though presentation has been delayed as long as 18 years.[12,15] The common symptoms of abdominal distention, pain, and vomiting mimic postoperative obstruction.[16] At the time of surgical exploration, strictures, previous perforations, and adhesions have been identified as the cause of obstruction in patients with posttraumatic small bowel obstructions.[4,14-16,20] In one case report, a motor vehicle crash caused abdominal pain and an adhesional small bowel obstruction without structural abnormalities of the intestine.[4]
In our case, a motor vehicle crash presumably caused an intestinal contusion, eventually resulting in adhesion formation and intermittent obstruction. Any source of severe blunt abdominal trauma, such as contact sports or biking accidents with resultant peritoneal injury, could cause adhesions by the same mechanism; peritoneal contusion associated with a decrease in fibrinolysis can result in the development of adhesions. Perhaps unrecognized "trauma" accounts for a portion of unexplained adhesional obstructions.[2,6,7] Recurrent obstructive symptoms should therefore prompt the clinician to take a thorough history of abdominal trauma.[5,21]
This case also portrays the difficulty of diagnosing an intermittent partial small bowel obstruction. Enteroclysis correctly diagnoses an adhesive small bowel obstruction in as many as 87.8% of patients.[22] False-negative studies occur and are more likely if the enteroclysis is done when the patient is asymptomatic.[22] Johnson et al [22] advocated the use of radiopaque markers, which collect proximal to the obstruction, to unmask adhesive obstructions. Results of our patient's initial enteroclysis were entirely normal, even on subsequent review. In comparison, when he was symptomatic, the study revealed a high density of contrast material proximal to an obstructing band, and the diagnosis of partial small bowel obstruction was made.

Urinary Bladder Injuries

Bladder injuries occur as a result of blunt or penetrating trauma. The probability of bladder injury varies according to the degree of bladder distention; therefore, a full bladder is more likely to become injured than an empty one.

Although uniformly fatal in the past, a timely diagnosis with appropriate medical and surgical management now offers an excellent outcome. Early clinical suspicion, appropriate and reliable radiologic studies, and prompt surgical intervention, when indicated, are the keys to successful diagnosis and management.

History of the Procedure: 
Patients with signs and symptoms suggestive of a bladder injury have a history typical for pelvic trauma, which is fairly straightforward for motor vehicle accidents, deceleration injuries, or assaults to the lower abdomen. If the patient is unconscious, family members or, more often, emergency services personnel can provide the history. 
Bladder injury from a motor vehicle accident may occur from direct impact with the car or indirectly from the steering wheel or seatbelt. 
Deceleration injuries of the urinary bladder usually result from falling from a great height and landing on unyielding ground. 
Assault to the lower abdomen by a sharp kick or blow may result in a bladder perforation. 
Penetrating injuries to the bladder usually result from high-velocity gunshots or sharp stab wounds to the suprapubic area.

Problems: 

Blunt trauma
Deceleration injuries usually produce both bladder trauma (perforation) and pelvic fractures. Approximately 10% of patients with pelvic fractures also have significant bladder injuries. The propensity of the bladder to sustain injury is related to its degree of distention at the time of trauma. 
Penetrating trauma 
Assault from a gunshot or stabbing typifies penetrating trauma. Often, concomitant abdominal and/or pelvic organ injuries are present. 

Obstetric trauma
During prolonged labor or a difficult forceps delivery, persistent pressure from the fetal head against the mother’s pubis can lead to bladder necrosis. Direct laceration of the urinary bladder is reported in 0.3% of women undergoing a cesarean delivery. Previous cesarean deliveries with resultant adhesions are a risk factor. Undue scarring may cause obliteration of normal tissue planes and facilitate an inadvertent extension of the incision into the bladder. Unrecognized bladder injuries may lead to vesicouterine fistulas and other problems. 

Gynecologic trauma 
Bladder injury may occur during a vaginal or abdominal hysterectomy. Blind dissection in the incorrect tissue plane between the base of the bladder and the cervical fascia results in bladder injury. Women with no history of pelvic radiation are at higher risk. 

Urologic trauma
Perforation of the bladder during a bladder biopsy, cystolitholapaxy, transurethral resection of the prostate (TURP), or transurethral resection of a bladder tumor (TURBT) is not uncommon. Incidence of bladder perforation is reportedly as high as 36% following bladder biopsy. 

Orthopedic trauma 
Orthopedic pins commonly perforate the urinary bladder. Thermal injuries to the bladder wall may occur during the setting of cement substances used to seat arthroplasty prosthetics. 

Idiopathic bladder trauma 
Patients diagnosed with alcoholism and those individuals who chronically imbibe a large quantity of fluids are susceptible to this type of injury. Previous bladder surgery is a risk factor. In reported cases, all bladder ruptures were intraperitoneal. This type of injury may result from a combination of bladder overdistention and minor external trauma (eg, a simple fall). 

Frequency: 
Frequency of bladder rupture varies according to the following mechanisms of injury: 
External trauma (82%) 
Iatrogenic (14%) 
Intoxication (2.9%) 
Spontaneous (<1%)

Of all bladder injuries, 60-85% are from blunt trauma and 15-40% are from a penetrating injury. The most common mechanisms of blunt trauma are motor vehicle accidents (87%), falls (7%), and assaults (6%). In penetrating traumas, the most frequent culprit is gunshot wounds (85%), followed by stabbings (15%). 
Approximately 10-25% of patients with a pelvic fracture also have urethral trauma. Conversely, 10-29% of patients with posterior urethral disruption have an associated bladder rupture. 

Traumatic bladder ruptures 
Of traumatic ruptures, extraperitoneal bladder perforations account for 50-71%, intraperitoneal accounts for 25-43%, and combined perforations account for 7-14%. Incidence of intraperitoneal bladder ruptures is significantly higher in children because of the predominantly intra-abdominal location of the bladder prior to puberty. 
Combined intraperitoneal and extraperitoneal ruptures account for approximately 10% of all traumatic bladder-perforating injuries. Mortality rates in these patients approach 60%, as compared to 17-22% overall, reflecting the severity of concomitant injuries associated with combined bladder ruptures. 

Associated bowel injuries 
Incidence is reportedly as high as 83% in patients with gunshot wounds. Colon injuries are reported in 33% of patients with stab wounds, and vascular injuries are reportedly as high as 82% in patients with a penetrating trauma (with a 63% mortality rate). 

Etiology:
Main causes of bladder injury are penetrating and blunt trauma. Iatrogenic causes include surgical misadventures from gynecologic, urologic, and orthopedic operations near the urinary bladder. Less common causes involve obstetric trauma. Spontaneous or idiopathic bladder injuries without an obvious underlying pathology constitute the remainder.

Pathophysiology: 
Bladder contusion is an incomplete or partial-thickness tear of the bladder mucosa. A segment of the bladder wall is bruised or contused, resulting in localized injury and hematoma. Contusion typically occurs in the following clinical situations: 
Patients presenting with gross hematuria after blunt trauma and normal imaging studies 
Patients presenting with gross hematuria after extreme physical activity (ie, long-distance running)

The bladder may appear normal or teardrop shaped on cystography. Bladder contusions are relatively benign, are the most common form of blunt bladder trauma, and are usually a diagnosis of exclusion. Bladder contusions are self-limiting and require no specific therapy, except for short-term bed rest until hematuria resolves. Persistent hematuria or unexplained lower abdominal pain requires further investigation. 

Extraperitoneal bladder ruptures 
Traumatic extraperitoneal ruptures usually are associated with pelvic fractures (89-100%). Previously, the mechanism of injury was believed to be from a direct perforation by a bony fragment or a disruption of the pelvic girdle. It is now generally agreed that the pelvic fracture is likely coincidental and that the bladder rupture is most often due to a direct burst injury or the shearing force of the deforming pelvic ring. 

These ruptures usually are associated with fractures of the anterior pubic arch, and they may occur from a direct laceration of the bladder by the bony fragments of the osseous pelvis. The anterolateral aspect of the bladder typically is perforated by bony spicules. Forceful disruption of the bony pelvis and/or the puboprostatic ligaments also tear the wall of the bladder. The degree of bladder injury is directly related to the severity of the fracture. 

Some cases may occur by a mechanism similar to intraperitoneal bladder rupture, which is a combination of trauma and bladder overdistention. The classic cystographic finding is contrast extravasation around the base of the bladder confined to the perivesical space; flame-shaped areas of contrast extravasation are noted adjacent to the bladder. The bladder may assume a teardrop shape from compression by a pelvic hematoma. Starburst, flame-shape, and featherlike patterns also are described. 

With a more complex injury, the contrast material extends to the thigh, penis, perineum, or into the anterior abdominal wall. Extravasation will reach the scrotum when the superior fascia of the urogenital diaphragm or the urogenital diaphragm itself becomes disrupted. 

If the inferior fascia of the urogenital diaphragm is violated, the contrast material will reach the thigh and penis (within the confines of the Colles fascia). Rarely, contrast may extravasate into the thigh through the obturator foramen or into the anterior abdominal wall. Sometimes, the contrast may extravasate through the inguinal canal and into the scrotum or labia majora. 

CT Scan
   This is often the first test performed on patients with blunt abdominal trauma. Although CT scan of the pelvis provides information on the status of the pelvic organs and osseous pelvis, static cystogram is superior in the diagnosis of bladder ruptures. 

Relevant Anatomy: 
The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the space of Retzius. The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis. 
In males, the bladder neck is contiguous with the prostate, which is attached to the pubis by puboprostatic ligaments. In females, pubourethral ligaments support the bladder neck and urethra. 
The body of the bladder receives support from the urogenital diaphragm inferiorly and the obturator internus muscles laterally. 
The superior fascia of the urogenital diaphragm is continuous and includes the pelvic, obturator, and endopelvic fasciae. The inferior fascia of the urogenital diaphragm fuses with the Colles fascia. It continues as the Scarpa fascia anteriorly, the dartos muscle and fascia in the scrotum, and the fascia lata of the thigh. 

The type of extravasation (intraperitoneal or extraperitoneal) depends upon the location of the laceration and its relationship with the peritoneal reflection. 
If the perforation is above the peritoneal reflection, the extravasation is intraperitoneal. 
If the injury is below the peritoneal reflection, the extravasation is extraperitoneal.
With an anterosuperior perforation, urinary extravasation may be intraperitoneal, extraperitoneal (space of Retzius), or both. If the tear is posterosuperior, fluid can spread intraperitoneally and/or retroperitoneally. 

In a bladder rupture, the superior fascia of the urogenital diaphragm, when intact, prohibits extravasation from escaping the pelvis. Inferior fascia of the urogenital diaphragm, when intact, also prevents urinary extravasation from flowing into the perineum.
 

Coauthored by
Coauthored by Benjamin Battino, MD, Staff Physician, Department of Surgery, Division of Urology, University of Cincinnati College of Medicine 
Jong M Choe, MD, FACS, is a member of the following medical societies: American Association of University Professors, American College of Surgeons, American Medical Association, American Urological Association, MedChi, Ohio State Medical Association, and Ohio Urological Society 
Edited by Toby C Chai, MD, FACS, Assistant Professor, Department of Surgery, Division of Urology, University of Maryland School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine; J Stuart Wolf, Jr, MD, Director of Michigan Center for Minimally Invasive Urology, Associate Professor, Department of Urology, University of Michigan Medical Center; and Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Assistant Clinical Professor, Department of Urology, Medical College of Ohio
 
 

Adhesions & Scars

Scars and Adhesions

Adhesions have been implicated as causing infertility, intestinal obstruction, and chronic pelvic pain. Data suggests that 67% to 93% of patients will develop adhesions following abdominal surgery and 55% to 100% of patients will develop adhesions following gynecologic surgery.3

Adhesion formation occurs after trauma to the tissues, and is caused by an inflammatory response due to tissue damage. As the body’s tissues heal and adhesions are formed, the tissues begin to shrink somewhat, which results in dysfunctional movement of the area. This, in turn, creates more mechanical irritation, perpetuating the cycle of adhesion formation. Adhesions tend to persist long after the original trauma has healed, attaching to organs, nerves, muscles and other neighboring structures. Adhesions tend to form following surgery, inflammation, trauma or radiation therapy treatment.

Adhesion Formation

Many people experience decreased movement and function as well as increased tissue tension following injuries, surgeries and infections. Like scars which form on our skin, adhesions from surgery, inflammations or injury become "internal scars." They may become painful and sometimes inhibit proper function by adhering tissues and organs which are designed to move freely. This can result in pain, discomfort or dysfunction. Mechanical problems can occur in your body due to the adhesions formed following the original injury, surgery or infection. Pain and dysfunction can also occur due to the body’s compensations in response to the injury, surgery or infection. Our therapists are highly trained in treating both of these causes of pain and dysfunction.

When adhesions form around the stomach, intestines or digestive tract, dysfunction such as constipation or abdominal pain may result. When it occurs around the uterus, ovaries, fallopian tubes or the delicate fimbriae of the uterine tubes, infertility may result.

Surgeries are a major cause of adhesions and scarring. Some surgeries which may cause adhesions or scars to form in and around organs include:
1) heart and lung surgery
2) appendectomy
3) episiotomy or C-section
4) laparoscopy or laparotomy
5) hysterectomy
6) back or hip surgery
7) abortion
8) gastric bypass
9) plastic surgery, and 
10) complete or partial removal of organs

Adhesions may cause problems near sites of surgery,
inflammation, trauma or radiation therapy. . . .

Inflammation or Infections often cause adhesions. Some which may cause adhesions include:
1) colitis
2) diverticulitis
3) gastritis
4) gastroenteritis
5) cholecystitis
6) perforated ulcer
7) pelvic inflammatory disease (PID)
8) endometriosis
9) cystitis or vaginitis
10) perforated diverticulum, small or large bowel
11) appendicitis
12) hepatitis 

Scars from trauma or radiation therapy often cause adhesions to form. Trauma may include falls, accidents, physical or sexual abuse. Radiation therapy can cause adhesions to form at the sites of cancer treatment or surrounding tissues. Inflammation following trauma or radiation therapy may cause adhesions to spread to neighboring organs unless they are removed or diminished by a physician or therapist trained to treat them. Symptoms sometimes appear far from the site of the original trauma.

Adhesion and Scar Release Treatment

Alternative Treatment Without Surgery or Drugs, a "Hands-on" Approach

The primary goal of our manual therapy is to increase mobility (motion) and decrease pain. This is done by using the hands to apply a gentle, specific stretch for a sustained period of time to tightened areas in the body’s connective tissues until the tension releases. This results in permanent elongation and improved mobility of the soft tissues

A major focus of our treatment is in treating adhesions in the "soft tissues" of the body. Soft tissues include:
1) muscles (which help us move), 
2) organs (which help us function), 
3) nerves (which alert us to problems, through pain), and 
4) ligaments (which connect bone to bone) and tendons (which connect muscles to bone), and
5) fascia, or connective tissue (which supports and separates all of the body structures, and is one of our main shock absorbers).

We have helped many people who suffer from on going pain from scars and adhesions. Our directors spent years studying techniques and developing protocols to restore patients’ bodies to a state of balance, harmony and increased function. Our treatment sessions are individualized and last approximately one hour based on individual needs. Treatment is one-on-one, and is in private treatment rooms. From your first visit, we use a "hands-on" approach to treat your symptoms and discover the causes of your pain. We begin by treating tight and dysfunctional areas in your body. 

A few minutes into your first treatment, our therapists will be providing a gentle stretch for a sustained period of time to areas of your body where we feel abnormal tensions. This has been very effective in decreasing and frequently resolving pain symptoms. Our goals of treatment are to restore alignment, balance and mobility to the pelvis, sacrum, thoracic and lumbar spines, the back and hip muscles, connective tissues, and abdominopelvic organs. Other treatment goals include decreasing pain and restoring range of motion. We work with you to improve your function, your tolerance for physical activity and return you to an active, productive lifestyle.

Patients generally discover within three treatments if our work will be effective in decreasing pain and other symptoms.  As pain decreases and function begins to return, we educate patients in a lifelong preventive and restorative exercise program to improve flexibility, strength, lifting ability and endurance levels. Enhancement of personal and professional life generally follows as a result. We work hand in hand with your physician, although physician referral is not required in the state of Florida for our work.

Treatment methods vary significantly. Many people do not obtain pain resolution after conservative treatment such as traditional physical therapy and medications. While most physicians agree that surgery is a treatment of last resort, a percentage of people do not obtain pain relief even after one or more surgeries.

A few minutes into your first treatment, our therapists will be providing a gentle stretch for a sustained period of time to areas of your body where we feel abnormal tensions. This has been very effective in decreasing and frequently resolving pain symptoms. Our goals of treatment are to restore alignment, balance and mobility to the pelvis, sacrum, thoracic and lumbar spines, the back and hip muscles, connective tissues, and abdominopelvic organs. Other treatment goals include decreasing pain and restoring range of motion. We work with you to improve your function, your tolerance for physical activity and return you to an active, productive lifestyle.

Patients generally discover within three treatments if our work will be effective in decreasing pain and other symptoms.  As pain decreases and function begins to return, we educate patients in a lifelong preventive and restorative exercise program to improve flexibility, strength, lifting ability and endurance levels. Enhancement of personal and professional life generally follows as a result. We work hand in hand with your physician, although physician referral is not required in the state of Florida for our work.

What should I expect from treatment?

The best way to determine if this work will help you is to schedule two to three visits. After three visits, most patients find their pain level noticeably improved. After six visits, they begin to notice significant structural and functional improvement in their bodies. Our goal is to help you achieve a pain free, more functional and productive life, with all your goals met.

If you have questions, we can schedule a personal consultation in one of our clinics or over the telephone. If treatment appears indicated, we will send you all necessary paperwork including a medical history questionnaire and release of medical records. We may request clearance from your physician for the very few conditions which would prevent us from treating you. These include diseases such as HIV and active cancer which could possibly worsen with treatment. Other contraindications are hemophilia, abnormal cysts and active infection.

Your treatment is always conducted in a lovely, private room. The first treatment includes an initial evaluation, and lasts up to 1½ hours. Thereafter, treatment sessions are generally 45 minutes of uninterrupted manual therapy. As manual therapists who often work on delicate areas, we are sensitive to your physical and emotional comfort level. We feel you should be fully informed in every step of treatment. We take the time to explain our theories and techniques while we are working with you. Your personal privacy is respected. Patient gowns are available each session for those who would like to use them.

Treatment feels similar to massage

But calling our work massage is like calling the space shuttle an airplane. Our work is a very "site specific" slow and deep body work to the soft tissues of your body. We use our hands to locate abnormal tensions in and around the organs, muscles, connective tissues and support structures of the body. We then apply gentle, specific sustained manual forces designed to reduce adhesions and encourage normal mobility, tone and function. Most patients say they find treatment sessions interesting, informative and relaxing. Most patients with pain complaints usually begin to notice pain reduction or relief after the first two or three sessions.

Therapist Qualifications

Therapist qualifications are a significant part of your comfort level. We invite you to visit our "About Us" page.  Belinda Wurn is a physical therapist with more than 20 years experience. Larry Wurn is a massage therapist with more than 10 years experience. Both are nationally certified body workers who have performed literally thousands of manual therapy treatments. They are therapists trained and licensed to practice manual ("hands-on") therapy in Florida in their respective fields of physical therapy and massage therapy.

Following licensure, they both attended extensive continuing education courses, as well as many courses on manual pelvic, urogenital and abdominal therapy treatment in America. They furthered their education by studying manual urogenital therapy at an osteopathic medical school in France. Their goal is to provide a quality and level of service which is unavailable anywhere in our area. Clear Passage Therapies’ staff is committed to give our patients the finest one-on-one treatment available, in a relaxed and healing setting.

All pages copyright 1998 © Clear Passage Therapies, Inc.

Non-surgical treatment for this condition Back
Endometriosis is a common, poorly understood disease. It is estimated that between 10 and 20 percent of American women of childbearing age have endometriosis. While some women with endometriosis may have severe pelvic pain, others who have the condition have no symptoms. The disease can affect a woman’s whole existence-her ability to work, her ability to reproduce, and her relationship with her mate, her children, her fellow workers, and everyone around her. 
The name "endometriosis" comes from the word "endometrium," the tissue that lines the inside of the uterus. If a woman is not pregnant, this tissue builds up and is shed each month. This tissue is normally discharged as menstrual flow each month.
Endometriosis refers to a condition in which endometrial tissue is found outside the uterus, usually inside the abdominal cavity. Endometrial tissue outside the uterus responds to the menstrual cycle similar to the way it would respond in the uterus. At the end of every cycle, when hormones cause the uterus to shed its endometrial lining, endometrial tissue growing outside the uterus tends to break apart and bleed.
Unlike menstrual fluid from the uterus, which is discharged from the body during menstruation, blood from the misplaced tissue has no place to go. Tissues surrounding the area of endometriosis often become inflamed or swollen. This inflammation may produce scar tissue around the area of endometriosis. These endometrial sites may develop into what are called "implants," "lesions," "growths" or "nodules."
Endometriosis can cause abdominal, pelvic or low back pain or dysfunction, including infertility.  Due to tiny adhesions which form as part of the healing process, endometriosis may cause symptoms long after the inflammation has passed.  Other conditions such as sexually transmitted and pelvic inflammatory diseases, vaginal, bladder or yeast infections may cause similarly adhered conditions. 

 Adhesions may cause pain, poor function or infertility

While endometriosis may form in many parts of the body, it is most often found:

1. in the ovaries 
2. on the fallopian tubes 
3. on the ligaments supporting the uterus 
4. in the internal area between the vagina and rectum 
5. on the outer surface of the uterus, and 
6. on the lining of the pelvic cavity. 

Less frequently, endometrial growths are found:

1. on the intestines 
2. in the rectum 
3. in the bladder 
4. on the vagina, cervix and vulva 
5. in abdominal surgery scars. 

The most common symptom of endometriosis is pain, especially excessive menstrual cramps (dysmenorrhea) which may be felt in the abdomen or lower back. This pain may begin before a woman’s period and several days after. Other symptoms may include:

1. occasional heavy periods 
2. sharp pain deep in the pelvis during sexual intercourse (dyspareunia) 
3. infertility 
4. pain during bowel movements. 

Infertility occurs in 30 to 40 percent of women with endometriosis, which is considered one of the major causes of female infertility. 

Vick in 1932
POSTOPERATIVE ADHESIVE INTESTINAL OBSTRUCTION
Ketan R Vagholkar
Practising Surgeon; Dr. Vagholkar’s Fracture and Accident Hospital, Thane - 400602

Adhesions have now become the leading cause of intestinal obstruction. The diagnosis though being straight forward, management poses a lot of problems due to the high incidence of recurrence. The advent of laparoscopic surgery may alter the incidence of adhesions. Despite the promise of laparoscopic surgery adhesions still continue to be a major source of concern for surgeons not only because of technical difficulties but also because of the volume of work they generate. In the absence of any clinically proven means of preventing adhesions from forming, the onus lies with the surgeon to try and reduce their occurrence by improved and meticulous surgical techniques.

INTRODUCTION
The clinical presentation of intestinal obstruction is well known to all surgeons when the patient presents with a previous history of abdominal surgery, the most likely diagnosis is adhesions.[10] The incidence of postoperative adhesive intestinal obstruction has been gradually increasing over the last few decades. Vick in 1932reported that adhesions accounted for 7% of all cases of intestinal obstruction.[35] During the last few decades the leading cause of intestinal obstruction was strangulated external hernia. The overall incidence of adhesive intestinal obstruction in 30% as shown in the studies conducted by Nemir, Perry, Bevan and Mc Entee.[2],[23],[26] Subsequent studies have revealed a steady rise in the incidence of intestinal obstruction to the present day incidence of about 40%.[2]

INCIDENCE
Various studies have been carried out to assess the severity of problems posed by adhesions. Weibel and Majno carried out a study in a post mortem series to find out the incidence of adhesions.[21,22] In cadavers with no preceding abdominal surgery, adhesions were found in 28% and in those that had minor abdominal surgery 67% had adhesions[21,22] With other abdominal surgery the reported incidence was 50%. If major surgery had been performed adhesions were present in 76% and in cases of multiple abdominal surgery 93% had adhesions.[18]
The incidence of adhesions has also been studied in living subjects. Inflammatory adhesions in patients who have not undergone any preceding abdominal surgery were found to be present in 10%. In patients who had previous abdominal surgery postoperative adhesions were found in 93% and inflammatory adhesions in 20%.[18]
In a review over the last 25 years it has been shown that adhesions accounted for 1% of all surgical admissions and 3% of all laparotomies in a particular surgical unit.[18] It is likely that although the incidence of adhesive obstruction is increasing, it is doing so because more and more patients are being submitted to laparotomies each year.[27]

AETIOPATHOGENESIS OF ADHESIONS
Adhesions can be classified as either congenital or acquired. The acquired type is further classified into inflammatory and post surgical. Of all the types described majority of cases are postsurgical. Many studies have been performed to study the time interval from surgery to obstruction. As yet results are not conclusive. The incidence though difficult to be determined is put forward to be 3% of all laparotomies for adhesive obstruction.[18]
All operations which involve handling of the viscera in the infracolic compartment are more likely to produce adhesive intestinal obstruction[32] The possible explanation put forward for them is trauma to the small bowel at the time of surgery.[7]
The anatomical distribution of all adhesions have been studied in various studies.[33] The most common site for adhesions were to the undersurface of the abdominal wound which occurred in 84% or to the site of previous surgery in 58%.[14,15,16] The omentum was commonly involved in adhesions to the scar (72%) and to the site of previous surgery (22%). Adhesions from the small bowel to the wound occurred in only 18% of wounds and from the small bowel to the site of surgery in 16%.[14,15,16] Adhesions which involved the small bowel alone occurred in only 8% of cases. Overall the omentum was involved in 57% of sites for adhesions and the small bowel was involved in 27% of sites. Adhesions between the small bowel and the site of previous surgery caused obstruction in 52%. Adhesions which involved the small bowel alone caused obstruction in 24%.[14,15,16] If the distribution of these obstructing adhesions is compared with that of any adhesions that develops after abdominal surgery, it is clear that although omental adhesions are the most common adhesions to be found they are at low risk of producing intestinal obstruction. Adhesions between small bowel and other viscera or other loops of small intestine occur less frequently but are far more likely to cause adhesive obstruction. The omentum plays a protective role in adhesion formation. Adhesive obstruction after total colectomy is well known. This is because the operation involves, omentectomy and this will remove the organ that forms safe adhesions. As a result it would leave adhesiogenic areas exposed to the small bowel and will result in higher incidence of small bowel adhesions.
Another significant factor is a frequent practice to divide any adhesions that are encountered. The division of adhesions which involves the small bowel are at a high risk of later obstruction.

PREVENTION
As yet there are no definite methods of completely preventing adhesions. The two commonly used solutions that have anti-adhesive effects in animals povidone iodine and 30% dextran 70.[13] Povidone iodine is used by surgeons more for its antimicrobial action rather than that of its anti adhesive effect.[11] Dextran is a popularly used solution in gynaecologic practice to prevent adhesions in infertility surgery.
The most important way of preventing adhesions is by meticulous technique. The following are a few operative steps which could be undertaken to reduce the incidence of post operative adhesions.
Careful handling of the bowel to reduce serosal trauma. 
Avoid rough unnecessary dissection. 
Avoid contact of foreign material from the peritoneum e.g. use of absorbable material as far as possible, avoid excess use of guaze swabs, or wearing starch free gloves. 
Adequate excision of ischaemic or infected debris within the peritoneum. 
Preserve the omentum as far as possible. Placement of omentum around the site of surgery and run the omentum under the wound to encourage low risk adhesions to form. 
Avoid dividing adhesions which do not involve the small intestines. 

SURGICAL MANAGEMENT
Adhesions producing intestinal obstruction usually require surgical intervention in 30 to 60% of cases.[1,2,3]
Simple adhesiolysis is usually employed in those patients who require surgery for adhesive obstruction. Recurrence rate after adhesiolysis is 11% to 21%.[5] In patients with recurrent obstruction adhesiolysis is combined with a plication procedure or with an insertion of a long intestinal tube.[6] The plication procedures of Noble or Childs and Philips depend upon sutures to hold the small bowel in a specific position so that further adhesive obstruction cannot occur.[9] The long intestinal tube is designed to hold the small bowel in a series of open loops until subsequent adhesions form to maintain the bowel in position and then the tube can be removed.[4] The noble plication has a high incidence of complication hence it is abandoned.[24,26] Although good results have been reported for the long intestinal tubes its use should be confined to patients after division of extensive intraabdominal adhesions.[6]
If used after division of only a few adhesions when the adhesions reform they may not be extensive enough to hold all the small bowel in an open looped position and therefore will permit movement and twisting of the bowel and allow subsequent adhesive intestinal obstruction to develop.[2],[19]

RECENT ADVANCES
Though there is a better understanding of the mechanisms which lead to adhesion formation, yet there is no pharmacological means of preventing the formation of adhesions. Peritoneal trauma and ischaemia are potent stimuli for adhesion formation.
Von Benzer has demonstrated fibrinolytic properties in peritoneum.[20] The fibrinolytic activity is thought to be contained within the mesothelial cell layer.[28,29] The fibrinolytic activity has been identified as plasminogen activation.[30,34] A reduction in this activity is linked to adhesion formation. Changes in plasminogen activator activity levels were shown to be due to stimuli well known to cause adhesions and were particularly marked in the presence of ischaemia. This reduction was not only due to removal of plasminogen activity but also due to the release of plasminogen activator inhibitors present during inflammation and ischaemia.[7,8,12]
This mechanism for adhesion formation supports the use of fibrinolytic agents as anti-adhesion agents.[7]
The commercial production of tissue plasminogen activator rt-PA by recombinant DNA techniques has permitted the study of the use of this agent in adhesion formation.[21,22] It has been used to replace the reduced plasminogen activity of traumatised peritoneum. The effectiveness of rt-PA as an anti adhesive has been confirmed in animal models. Its effectivity in humans has still to be tried out. But it appears to be the most promising agent. Laparoscopic surgery may prove to be the solution to the problem. A study conducted by Luciano demonstrated that when a stimulus is applied at open laparotomy in an animal it produces more adhesions than when the same stimulus is applied through the laparoscope.[17]

CONCLUSION
The advent of laparoscopic surgery will undoubtedly alter the incidence of adhesions developing after surgery. The reduced bowel trauma from handling, the absence of large abdominal wounds and the exclusion of foreign material such as starch and guaze from the abdominal cavity will reduce adhesion formation after laparoscopic surgery.
It is possible that in the future these problems may be reduced by some form of rt-PA peritoneal lavage after surgery that will prevent adhesion formation or reformation. 
 

REFERENCES
Adhesion study group. Reduction of post operative pelvic adhesions with intraperitoneal 32% dextran 70 : a prospective randomised clinical trial. Fertil steril 1983; 40 : 612-19. 
Bevan PG. Adhesive Obstruction. An R Coll surg Engl 1984; 66 : 164-9. 
Bizer LS, Liebling RW, Delaney HM, Gliedman HL. Small bowel obstruction. The role of non operative treatment in simple intestinal obstruction and predictive criteria for strangulation obstruction surgery 1980; 407-13. 
Brightwell NL, Mcfee AS, Aust JB. Bowel obstruction and the long tube stent. Arch Surg 1977; 112 : 505-11. 
Bizer LS, Delaney HM, Genut Z. Observations on recurrent intestinal obstruction and modern non operative management. Diag Surg 1986; 3 : 229-31. 
Baker JW. A long jejunostomy tube for decompression in intestinal obstruction. Surg Gynaecol obstet 1959; 109 : 518-20. 
Buckman RF, Woods M, Sargent L, Gervin AS. A unifying pathogenetic mechanism in the etiology of intraperitoneal adhesions. J surg Res 1976; 20 : 1-5. 
Buckman RF, Buckman PD, Hufnagel HV, Gervin AS. A physiologic basis for adhesion free healing of deperitionealized surfaces. J surg Res 1976; 21 : 67-76. 
Childs WA, Philips RB. Experience with intestinal plication and a proposed modification. Ann surg 1960; 152 : 258-65. 
Fuzun M, Kayona KE, Harmanciouglu O, Astarciglu K. Principal causes of mechanical bowel obstruction in surgically treated adults in Western Turkey. Br J Surg 1991; 78 : 202-3. 
Gilmore OJA, Reid C. Prevention of peritoneal adhesions by a new povidone iodine /PVP solution. J surg Res 1978; 25 : 477-81. 
Germin AS, Puckett CL, Silver D. Serosal hypofibrinolysis. A cause for postoperative adhesions. Am J Surg 1973; 125 : 80-8. 
Holtz G, Baker ER. Inhibition of peritoneal adhesion formation after lysis with 32% dextran 70 fertil steril 1980; 34 : 294-5. 
Hofstetter SR. Acute Adhesive obstruction of the small intestine. Surg Gynaecol obst 1981; 152 : 141-4. 
Hall RI. Adhesive obstruction of the small intestine; a retrospective review. Br J clin Pract 1984; 38 : 89-92. 
Laws HL, Aldrete JS. Small bowel obstruction; a review of 465 cases. South med J 1976; 69 : 733-4. 
Luciano AA. Laparotomy versus laparoscopy. prog clin Biol Res 1990; 358 : 35-44. 
Menzies D, Ellis H. Intestinal obstruction from adhesions-how big is the problem? Ann R coll Surg Engl 1990; 72 : 60-3. 
Maetani S, Tobe T, Kashiwara S. The neglected role of torsion and constriction in pathogenesis of simple adhesive bowel obstruction. Br J surg 1984; 71 : 127-30. 
Mryhe Jenson O, Lassen SB, Astrup T. Fibrinolytic activity in seasonal and synovial membranes. Arch Path 1969; 88 : 623-30. 
Menzies D, Ellis H. Intra abdominal adhesions and their prevention by topical tissue plasminogen activator. J R Soc Med 1989; 82 : 534-5. 
Menzis D, Ellis H. The Role of plasminogen activator in adhesion prevention. Surg Gynaecol obstet 1990; 172 : 362-6. 
Nemir P. Intestinal obstruction: ten year surgery at the hospital of the University of pennsylvania. Ann Surg 1952; 135 : 367-75. 
Noble TB. Plication of small intestine as prophylaxis against adhesions. Am J surg 1937; 35 : 41-4. 
Nikitin Yu P, Shunkova EI, Sysoev AN, Severmy VY, Ledeneva OA. Fibrinolytic properties of human serous membranes. Arkh patol 1968; 30 : 66-9. 
Perry JF, Smith GA, Yonehiro EG. Intestinal obstruction caused by adhesions: a review of 388 cases. Ann surg 1955; 142 : 810-16. 
Plyforth RH, Holloway JB, Griffin WO. Mechanical small bowel obstruction: a plea for surgical intervention. Ann surg 1970; 171 : 183-8. 
Porter JM, MC Gregor FH, Mullen DC, Silver D. Fibrinolytic activity of mesothelial surfaces. surg forum 1969; 20 : 80-4. 
Raftery AT. Method of measuring fibrinolytic activity in a single layer of cells. J clini pathol 1981; 34 : 625-9. 
Raftery AT. Effect of peritoneal trauma on peritoneal fibrinolytic activity and intraperitoneal adhesion formation. An experimental study in the rat. Eur Surg Res 1981; 13 : 397-401 
Stewardson RH, Bombeck CT, Nyus LM. Critical operative management of strangulation obstruction. Ann surg 1978; 187 : 189-93. 
Stewart RM, Page CP, Brendar J, Sch wesinger W, Eisinhut D. The incidence and risk of early postoperative small bowel obstruction: a cohort study. Am J surg 1987; 154 : 643-7. 
Turner DM, Croom RD. Acute Adhesive obstruction of the small intestine. Am Surg 1983; 49 : 126-30. 
Vipond MN, Whavell SA, Thomson JN, Dudley HAF. Peritoneal fibrinolytic activity and intra abdominal adhesions. Lancet 1990; 335 : 1120-2. 
Vick RM. Statistics of acute intestinal obstruction. Br Med J 1932; 2 : 546-8. 

Pain after Surgery: What You Can Expect
by Robert B. Albee, MD

Just as each woman with endometriosis has a case like no one else's, so, too, can she expect her recovery to be as individual as she is. In other words, there is a very wide range of "normal" recovery after laparoscopic excision of endometriosis. 

For some women, some of the pain they had been experiencing before their operation will disappear immediately. Such cases are explained more fully below. For other women, their pain decreases at a steady rate over a few to many days or weeks. For still others, pain relief seems as though it will never happen, then a very dramatic corner is turned. Often, the older a woman is and the longer she's been sick, the longer her recovery may take. Of course, there are many exceptions.

Are there any guidelines as to what to expect?

First, let's discuss situations in which a patient might experience significant pain relief almost immediately. 

Internal pressure is relieved

In the course of excision of endometriosis, it is common to encounter areas where a build up of fluid or edematous (swollen) tissues occupy a confined space. For example, an endometrioma within the capsule of the ovary will create increasing pressure as it enlarges. Some women have areas of endometriosis that are encapsulated by adhesions. This can result in swollen tissue that has no place into which to expand. 

These areas of pressure exert a stretching effect on the local nerve endings. This can result in intense pain. When we release this pressure by excising the endometriosis and removing the adhesions the pain may disappear immediately.
 

Adhesions are the Bind that Ties

It is quite common for a woman with endometriosis to have adhesions (internal scar tissue) holding together two structures that need to move separately. For example, a woman's ovary moves in various ways throughout her menstrual cycle. If the ovary is stuck down with adhesions, these attempts at movement can cause great pain. If the ovary is attached to the bowel, for example, movement of either structure is going to trigger pain.

When the adhesions that are preventing independent movement of bodily structures are removed, the pain relief is often intense and immediate.
 

Lingering Pain

We are frequently asked why the pain doesn't go away in the first few days after surgery. After all, the reasoning goes, the endometriosis is out, so why should I have any pain?

Each area of endometriosis that is excised leaves behind a base of normal tissue which has been uncovered of its normal peritoneal surface. This is essentially a raw tissue which immediately becomes swollen with the body's natural response to injury. This also involves an increase in the local blood supply, and an infusion of defense cells such as plasma calls and white blood cells. 

This surgical "injury" requires a significant amount of time to heal. New peritoneum must be generated to cover the raw area. The swelling must have time to subside. The patient's nerve endings can't tell the difference between endometriosis and surgery to excise it: all they know is that something is causing them to fire, and the result can be pain. 

Frequently, the patient's next ovulation and/or menstrual period occur during the early stages of healing. These processes can add to the factors that create irritation of already swollen tissues. It is not uncommon, therefore, for the first ovulation and period after surgery to be quite painful. Also, the first period after surgery is often heavy, cramp, clotty, and long. Succeeding periods should be much more normal.
 

Take Heart

Although the tissue healing can take up to twelve weeks and seem as though it will never happen, there is much to look forward to. It is important to remember that while surgery is an event, healing is a process. 

Most women find that they are doing quite well by their third menstrual period after surgery. However, we have had many women report that they felt their healing took even longer. By 90 days post-op, virtually all patients have resumed normal activities. Significant numbers, however, report ongoing improvement, in very small increments, for up to one full year after surgery. 

The key point to remember is that until all the swelling is resolved on the inside where the endometriosis was excised, there is still a source of pain in exactly the same area previously affected by endometriosis.

Pain Following Radiation Therapy

Abdominal and Pelvic
Post-Radiation Scars

Radiation therapy is a life saving treatment for patients with malignancies (cancer). But radiation therapy can cause moderate to severe adhesion formation, attaching organs to other organs, muscles, bones, connective tissues and their support structures. When this happens, organs can lose their ability to function normally, causing a variety of symptoms. When nerves are involved, pain results.

Radiation therapy can cause adhesions to form at the sites of cancer treatment or surrounding tissues. Symptoms sometimes appear far from the site of the original trauma. Inflammation following trauma or radiation therapy may cause adhesions to spread to neighboring organs unless they are removed or diminished by a physician or therapist trained to treat them.

The pelvis and abdomen are common sites for radiation therapy. Organs must be able to move freely in the body. After pelvic radiation therapy treatment, a severe condition known as a "frozen pelvis" may occur. All or most of the organs, muscles, fascias and ligaments in the pelvic cavity become adhered to one another. Symptoms vary from pain or poor digestion or elimination to infertility, depending on the structures involved. Pelvic adhesions have been implicated as causing infertility, intestinal obstruction, and chronic pelvic pain.1,2 Common causes of a frozen pelvis include radiation therapy, endometriosis and post-surgical adhesions.

Clear Passage Therapies was created as a response to our own Clinical Director’s post-radiation and post-surgical pelvic adhesions. For several years now, we have studied, refined and developed conservative manual therapy techniques to reduce adhesions in the abdominopelvic region. We treat the soft tissues of the   abdomen and pelvis with our hands, using gentle, site specific therapy to decrease adhesions affecting muscles, organs, their connective tissues and their attachments. This conservative, non-surgical approach has been very effective with abdominopelvic adhesions and frozen pelvis.

Treatment of Radiation Scars and Adhesions

Alternative Therapy Without Surgery or Drugs, a "Hands-on" Approach

Treatment methods vary significantly. Many people do not obtain pain resolution after conservative treatment such as traditional physical therapy and medications. While most physicians agree that surgery is a treatment of last resort, a percentage of people do not obtain pain relief even after one or more surgeries.

We have helped many people who suffer from ongoing prior radiation therapy. Our directors spent years studying techniques and developing protocols to restore patients’ bodies to a state of balance, harmony and increased function. Our treatment sessions are individualized and last approximately one hour based on individual needs. Treatment is one-on-one, and is in private treatment rooms. From your first visit, we use a "hands-on" approach to treat your symptoms and discover the causes of your pain. We begin by treating tight and dysfunctional areas in your body. 

A few minutes into your first treatment, our therapists will be providing a gentle stretch for a sustained period of time to areas of your body where we feel abnormal tensions. This has been very effective in decreasing and frequently resolving pain symptoms. Our goals of treatment are to restore alignment, balance and mobility to the pelvis, sacrum, thoracic and lumbar spines, the back and hip muscles, connective tissues, and abdominopelvic organs. Other treatment goals include decreasing pain and restoring range of motion. We work with you to improve your function, your tolerance for physical activity and return you to an active, productive lifestyle.
Patients generally discover within three treatments if our work will be effective in decreasing their pain and other symptoms. As pain decreases and function begins to return, we educate in a lifelong preventive and restorative exercise program to improve flexibility, strength, lifting ability and endurance levels. Enhancement of personal and professional life generally follows as a result. We work hand in hand with your physician, although physician referral is not required in the state of Florida for our work.

What should I expect from treatment?

The best way to determine if this work will help you is to schedule two or three visits. After three visits, most patients find their pain level noticeably improved. After six visits, they begin to notice significant structural and functional improvement in their bodies. Our goal is to help you achieve a pain free, more functional and productive life, with all your goals met.
If you have questions, we can schedule a personal consultation in one of our clinics or over the telephone. If treatment appears indicated, we will send you all necessary paperwork including a medical history questionnaire and release of medical records. We may request clearance from your physician for the very few conditions which would prevent us from treating you. These include diseases such as HIV and active cancer which could possibly worsen with treatment. Other contraindications are hemophilia, abnormal cysts and active infection.
Your treatment is always conducted in a lovely, private room. The first treatment includes an initial evaluation, and lasts up to 1½ hours. Thereafter, treatment sessions are generally 45 minutes of uninterrupted manual therapy. As manual therapists who often work on delicate areas, we are sensitive to your physical and emotional comfort level. We feel you should be fully informed in every step of treatment. We take the time to explain our theories and techniques while we are working with you. Your personal privacy is respected. Patient gowns are available each session for those who would like to use them.

Treatment feels similar to massage

But calling our work massage is like calling the space shuttle an airplane. Our work is a very "site specific" slow and deep body work to the soft tissues of your body. We use our hands to locate abnormal tensions in and around the organs, muscles, connective tissues and support structures of the body. We then apply gentle, specific sustained manual forces designed to reduce adhesions and encourage normal mobility, tone and function. Most patients say they find treatment sessions interesting, informative and relaxing. Most patients with pain complaints usually begin to notice pain reduction or relief after the first two or three sessions.

Therapist qualifications are a significant part of your comfort level. We invite you to visit our "About Us" page.  Belinda Wurn is a physical therapist with more than 20 years experience. Larry Wurn is a massage therapist with more than 10 years experience. Both are nationally certified body workers who have performed literally thousands of manual therapy treatments. They are therapists trained and licensed to practice manual ("hands-on") therapy in Florida in their respective fields of physical therapy and massage therapy.

Following licensure, they both attended extensive continuing education courses, as well as many courses on manual pelvic, urogenital and abdominal therapy treatment in America. They furthered their education by studying manual urogenital therapy at an osteopathic medical school in France. Their goal is to provide a quality and level of service which is unavailable anywhere in our area. Clear Passage Therapies’ staff is committed to give our patients the finest one-on-one treatment available, in a relaxed and healing setting.